Image of the Month—Interactive Quiz

Figure 1.Computed tomographic scan of
the abdomen, sagittal cut.

Figure 2.Computed tomographic scan of
the abdomen.

John Kubasiak, BA; John Linn, MD; Marie Crandall, MD, MPH

A 75-year-old man presented to the
emergency department with 2 days of sudden-onset abdominal pain,
nausea, and 1 episode of hematemesis. He had been obstipated for a
similar period. He described his pain as epigastric with substernal
radiation. Review of systems was otherwise negative.

Abdominal examination revealed a distended abdomen with absent
bowel sounds. A mass was palpable in the upper abdomen, and
peritoneal signs were present. Cardiopulmonary examination was
normal. Vital signs and laboratory results showed a temperature of
38°C, white blood cell count of 22 000/μL (to convert to
x10
9/L, multiply by 0.001) with 92% neutrophils, hemoglobin
level of 16.3 g/dL (to convert to grams per liter, multiply by 10),
a total bilirubin level of 3.2 mg/dL (to convert to micromoles per
liter, multiply by 17.104), and a direct bilirubin level of 0.8
mg/dL (to convert to micromoles per liter, multiply by 17.104).
Computed tomographic scan with contrast of the chest and abdomen
was obtained (
Figure 1and
Figure 2). Fluid resuscitation was initiated.

He was taken to the operating room for endoscopy and laparotomy.
Esophagoscopy revealed a linear tear of the esophageal mucosa at
the Z line. No mass lesion or transmural perforation was
identified. Laparotomy revealed a large, soft, inflammatory mass
involving the jejunum approximately 60 cm distal to the ligament of
Treitz. The proximal small bowel was clearly obstructed. He
underwent small-bowel resection with primary anastomosis. The
stomach and the gastroesophageal junction were then submerged with
saline. A nasogastric tube was used to insufflate air into the
stomach and no bubbling was detected, so nothing further was done
to that area. The patient had an uneventful recovery and tolerated
a general diet prior to hospital discharge. He was seen in
follow-up 3 weeks after surgery with no complications.

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